Health inspection·June 2, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff and resident interview, review of a guest assistance form, and policy review, the facility failed to ensure residents were treated respectful by staff during care. This affected one resident (#78) out of three residents reviewed. The facility census was 78. Findings Include: Review of the medical record revealed Resident #78 admitted to the facility on [DATE]. Diagnoses included spinal stenosis, osteoarthritis, osteonecrosis, chronic viral hepatitis C, restless leg syndrome, chronic pain, spinal stenosis, and lumbar region with neurogenic claudication. Review of the plan of care (POC) dated 04/04/23 revealed Resident #78 was at risk for fluctuating incontinence of bladder and bowel related to impaired mobility, weakness, and physical deconditioning. Interventions included encourage independence, provide incontinent care with moisture barrier as needed, resident agreed to trial use of the bed pan, resident prefers one bed pad on the bed and likes to turn and defecate, resident preferred to be naked in bed, and used a urinal. Review of the minimum data set (MDS) assessment dated [DATE] revealed Resident #78 was cognitively intact. Resident #78 required the assistance on one to two staff for daily care including transfers. Review of the POC [NAME] revealed Resident #78's care included encourage independence with bed mobility while providing care and assist as needed, encourage to participate in self-care, resident agreed to trial the use of the bed pan, resident preferred one pad on the bed, turns to his side and defecates on the pad, resident preferred to remain naked in bed, and used the urinal. Review of a guest assistance form dated 05/09/23 revealed the Social Service (SS) #345 interviewed Resident #78 in regard to a complaint. Resident #78 had said State Tested Nursing Assistant (STNA) #506 had flipped resident with the incontinence pad and put Resident #78 in an uncomfortable position, left the guest in that spot while changing and leaving the resident to scream for help. SS #345 had documented in the facility response the incident was investigated and STNA #506' employment was terminated. Interview on 06/01/23 at 10:50 A.M., with Resident #78 said STNA #506 came into his room and used expletives asking where was the residents diaper. Resident #78 said he felt humiliated and no longer wanted the STNA in the room. STNA #506 grabbed his incontinent pad under him and rolled him onto his left side which caused some pain and left the room. Resident #78 stated he thought this incident (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 365598 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365598 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Laurels of West Carrollton The 115 Elmwood Circle West Carrollton, OH 45449 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)